ELECTIVE –I- 2.

Working with People living with HIV / AIDS

UNIT-1

Introduction to Sexually Transmitted Diseases

The term ‘Sexually Transmitted Diseases’ (abbreviated STDs) refers to a group of illnesses that can be
transmitted from one person to another through the sharing of body fluids, including ejaculate (“cum”),
vaginal fluids, blood, and other fluids. Apart from sharing similar ways of infecting people, the various
diseases compromising the STDs have little in common. They have a variety of different causes
(including bacteria and viruses), they produce a variety of symptoms (or absence of symptoms), and they
have very different effects on the body when left untreated.
STDs are transmitted when body fluids from an infected person come into intimate contact with another
person. As their name implies, the most common route through which this body fluid sharing occurs is
sexual activity. All forms of sexual activity may involve sharing of body fluids. Sexual contacts involving
any combination of genitals, anus, fingers and/or mouth can place a person at risk.
Sometimes these infections can be transmitted nonsexually, such as from mothers to their infants during
pregnancy or childbirth, or through blood transfusions or shared needles. STIs don't always cause
symptoms. It's possible to contract sexually transmitted infections from people who seem perfectly
healthy and may not even know they have an infection.

Symptoms

STDs or STIs can have a range of signs and symptoms, including no symptoms. That's why they may go
unnoticed until complications occur or a partner is diagnosed.

Signs and symptoms that might indicate an STI include:

 Sores or bumps on the genitals or in the oral or rectal area

 Painful or burning urination
 Discharge from the penis
 Unusual or odorous vaginal discharge
 Unusual vaginal bleeding
 Pain during sex
 Sore, swollen lymph nodes, particularly in the groin but sometimes more widespread
 Lower abdominal pain
 Fever
 Rash over the trunk, hands or feet
Signs and symptoms may appear a few days after exposure. However, it may take years before you have
any noticeable problems, depending on the organism causing the STI.
When to see a doctor

See a doctor immediately if:

 You are sexually active and may have been exposed to an STI
 You have signs and symptoms of an STI
Make an appointment with a doctor:

 When you're considering becoming sexually active or when you're 21 — whichever comes first
 Before you start having sex with a new partner

Causes

STDs or STIs can be caused by:

 Bacteria. Gonorrhea, syphilis and chlamydia are examples of STIs that are caused by bacteria.
 Parasites. Trichomoniasis is an STI caused by a parasite.
 Viruses. STIs causes by viruses include HPV, genital herpes and HIV.
Other kinds of infections — hepatitis A, B and C viruses, shigella infection and giardia infection — can
be spread through sexual activity, but it's possible to be infected without sexual contact.

Risk factors

Anyone who is sexually active risks some degree of exposure to an STD or STI. Factors that may increase
that risk include:

 Having unprotected sex. Vaginal or anal penetration by an infected partner who isn't wearing a
latex condom significantly increases the risk of getting an STI. Improper or inconsistent use of
condoms can also increase risk.
Oral sex may be less risky, but infections can still be transmitted without a latex condom or a dental
dam — a thin, square piece of rubber made with latex or silicone.

 Having sexual contact with multiple partners. The more people you have sexual contact with,
the greater your risk.
 Having a history of STIs. Having one STI makes it much easier for another STI to take hold.
 Being forced to engage in sexual activity. Dealing with rape or assault is difficult, but it's
important to see a doctor as soon as possible to receive screening, treatment and emotional support.
 Misuse of alcohol or use of recreational drugs. Substance misuse can inhibit your judgment,
making you more willing to participate in risky behaviors.
  Injecting drugs. Needle sharing spreads many serious infections, including HIV, hepatitis B and
hepatitis C.
 Being young. Half the new STIs occur in people between the ages of 15 and 24.

Transmission from mothers to infants

Certain STIs — such as gonorrhea, chlamydia, HIV and syphilis — can be passed from mothers to their
infants during pregnancy or delivery. STIs in infants can cause serious problems or even death. All
pregnant women should be screened for these infections and treated.

Complications

Because many people in the early stages of an STD or STI experience no symptoms, screening for STIs is
important to prevent complications.

Possible complications include:

 Pelvic pain
 Pregnancy complications
 Eye inflammation
 Arthritis
 Pelvic inflammatory disease
 Infertility
 Heart disease
 Certain cancers, such as HPV-associated cervical and rectal cancers

Prevention

There are several ways to avoid or reduce your risk of STDs or STIs.

 Abstain. The most effective way to avoid STIs is to not have (abstain from) sex.
 Stay with one uninfected partner. Another reliable way of avoiding STIs is to stay in a long-term
relationship in which both people have sex only with each other and neither partner is infected.
 Wait and test. Avoid vaginal and anal intercourse with new partners until you have both been
tested for STIs. Oral sex is less risky, but use a latex condom or dental dam to prevent skin-to-skin
contact between the oral and genital mucous membranes.
 Get vaccinated. Getting vaccinated early, before sexual exposure, is also effective in preventing
certain types of STIs. Vaccines are available to prevent human papillomavirus (HPV), hepatitis A
and hepatitis B.
The Centers for Disease Control and Prevention (CDC) recommends the HPV vaccine for girls and
boys ages 11 and 12, although it can be given as early as age 9. If not fully vaccinated at ages 11
and 12, the CDC recommends getting the vaccine through age 26.
The hepatitis B vaccine is usually given to newborns, and the hepatitis A vaccine is recommended
for 1-year-olds. Both vaccines are recommended for people who aren't already immune to these
diseases and for those who are at increased risk of infection, such as men who have sex with men
and IV drug users.
 Use condoms and dental dams consistently and correctly. Use a new latex condom or dental
dam for each sex act, whether oral, vaginal or anal. Never use an oil-based lubricant, such as
petroleum jelly, with a latex condom or dental dam.
Condoms made from natural membranes are not recommended because they're not effective at
preventing STIs. Also, keep in mind that while latex condoms reduce your risk of exposure to
most STIs, they provide less protection for STIs involving exposed genital sores, such as HPV or
herpes.
Also, nonbarrier forms of contraception, such as birth control pills or intrauterine devices (IUDs),
don't protect against STIs.

 Don't drink alcohol excessively or use drugs. If you're under the influence, you're more likely to
take sexual risks.
 Communicate. Before any serious sexual contact, communicate with your partner about practicing
safer sex. Be sure you specifically agree on what activities will and won't be OK.
 Consider male circumcision. For men, there's evidence that circumcision can help reduce the risk
of acquiring HIV from a woman with HIV by as much as 60%. Male circumcision may also help
prevent transmission of genital HPV and genital herpes.
 Consider using preexposure prophylaxis (PrEP). The Food and Drug Administration (FDA) has
approved the use of two combination drugs to reduce the risk of HIV infection in people who are at
very high risk. They're emtricitabine plus tenofovir disoproxil fumarate (Truvada) and emtricitabine
plus tenofovir alafenamide fumarate (Descovy).
Your doctor will prescribe these drugs for HIV prevention only if you don't already have HIV. You
will need an HIV test before you start taking PrEP and then every three months as long as you're
taking it.
Your doctor will also test your kidney function before prescribing Truvada and continue to test it
every six months. If you have hepatitis B, you should be evaluated by an infectious disease or liver
specialist before beginning therapy.
These drugs must be taken every day, exactly as prescribed. If you use Truvada daily, you can
lower your risk of getting HIV from sex by about 99% and from injection drug use by more than
74% percent, according to the U.S. Centers for Disease Control and Prevention. Research suggests
that Descovy is similarly effective in reducing the risk of getting HIV from sex. However, Descovy
hasn't been studied in people who have receptive vaginal sex. Using additional prevention, such as
condoms, can lower your risk even more and prevent other STIs.
 Reference
https://www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/symptoms-causes/syc-
20351240

More Information

 STD symptoms

https://www.urologyhealth.org/urology-a-z/s/sexually-
transmitted-infections- refer for what are Sexually Transmitted Infections (STIs) or
Diseases (STDs)?

Epidemiology of HIV/AIDS

What is Epidemiology
Epidemiology is the method used to find the causes of health outcomes and diseases in populations. In
epidemiology, the patient is the community and individuals are viewed collectively. By definition,
epidemiology is the study (scientific, systematic, and data-driven) of the distribution (frequency, pattern)
and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified
populations (neighborhood, school, city, state, country, global). It is also the application of this study to
the control of health problems
HIV/ AIDS IN INDIA REFER THE PDF DOCUMENT

Pre test and post test Counselling:

QUALITIES NEEDED IN A GOOD COUNSELLOR

# Should have patience

# Should be a good listener, sympathetic and attentive

# Should aim to help and not preach

# The attitude should be unbiased and non-judgemental

Should be a good communicator. Here the body language, verbal skills, choice of examples, and
#
expression all play an important role

# Ability to reach out to the patient and show empathy

# Ability to draw the patient to you and develop trust

# Willing to admit mistakes

# Willing to learn and search for right answers

# Drawing boundries of limitation both for you and the patient

# Provide accurate information. If you are caught making up "facts" or guessing, you will lose trust and
your role as a counsellor to that patient is compromised. (Patients in such situations will often test you,
 hoping you fail since that makes them feel less low.)

PRE-REQUISITES FOR SUCCESSFUL COUNSELLING

# Building a rapport

# Confidentiality of the interactions and establishment of trust

# Privacy during the meetings (one on one only)

# Sustainability of the effort

THERE IS A DIFFERENCE BETWEEN HEALTH EDUCATION AND COUNSELLING

HEALTH EDUCATION COUNSELLING

It is a one on one interaction involving

# It is a one to many communication
confidentiality, anonymity, privacy

One has to deal with personal issues of the

# One deals with issues is general
individual

One shares statistical information, data and analyses to

Have to understand the individual to make an
# show trends and dangers of (i) epidemics (ii) risky
impact on specific attitude and behavior
behavior.

# The interaction is impersonal The interaction can be very emotional

ESTABLISHING A RAPPORT

Establishing a rapport from the outset is very important.

INTELLIGENT PERSONS (graduates): They have partial knowledge and often have an attitude of
# superiority. You have to fill in the gaps in their knowledge before they will look up to you for
counselling

WOMEN: may prefer to work with a female counsellor. The issue of gender matching is important for
#
both sexes

WOMEN: If the male partner is responsible for risky behavior, it is important to encourage her to bring
#
along the partner. Gender bias or inequality in such situations is an important issue.

# STUDENT/ADOLESCENT: explore the reason for their trauma or fear

ILLITERATE: Need explicit visual material as talking about it and non-personal/abstract examples are
#
not easily assimilated

COUNSELLING TO MODIFY BEHAVIOR -- GENERALITIES

# Understand why the person has come to you -- what is troubling him/her.

# Identify the problem.

# Identify the behavior/attitude that has contributed to the problem.

# Make them aware of the consequences of their behavior/attitude.

Provide them with different options, along with an assessment of the risk for each, from which they
#
need to select one.

# Help evaluate the efficacy of the chosen option for that individual.

COUNSELLING TO MODIFY RISKY SEXUAL BEHAVIOR

Risky sexual behavior is an additive habit just like alcohol or drugs. It is very important to understand that
to change this behavior requires time, patience and expertise on the part of the counsellor.

# Overview of the reproductive organs in the human body.

# Provide an Overview of Sexually Transmitted Diseases (STD) in humans

Make the person aware of consequences of risky behavior -- Sexually Transmitted Diseases and
#
HIV/AIDS.

# Emphasize that there is no second chance with HIV/AIDS. Devastation for self and family

Explain OPTIONS for risk reduction: (i) Abstinence from sex, (ii) sex with only one partner, (iii)
#
Learning to have orgasms without penetration (iv) PROPER use of condom EVERY time

# Evaluate the patients choice to see if it is an attainable goal

# A good test of ability to put on the condom properly is to be able to do it blindfolded

# Make condoms available free to patient

# Re-evaluate the patient's knowledge regularly

# Continue the counselling until convinced that the patient will sustain the modified behaviory

COUNSELLING ON STD'S

# Review their case history of STD's with them

# Provide information on the different types of STD's -- bacterial (curable) and viral (no cure yet)

Explain why difference in transmission rate from man to women is about three times higher than from
#
woman to man. Women are at higher risk.

Explain the difference in symptoms between men and women for STD's like gonorrhea, chlay, Human
# Pappiloma Virus (HPV). Most Women show almost no symptoms but suffer very serious consequences
like Pelvic Inflammatory Disease (PID), cervical cancer, and infertility if untreated.
# Explain why it is essential for both partners to get tested

Motivate change in sexual behavior to avoid future STI's and HIV/AIDS. Schedule next meeting in 3
#
months to review progress

GOALS OF HIV/AIDS COUNSELLING

# It is designed to help the patient cope with the information related to the disease and the test

# Provide understanding of what the test results mean

# Informed consent before the test

If test result is positive then the patient is taught to understand his/her social responsibilities, and to
#
develop skills to cope with the infection.

If the test is negative, work to increase their level of information and understanding of the
#
consequences of HIV infection. Motivate a change in behavior that reduces risk of getting infected

PRE-TEST COUNSELLING (25-30 minutes)

# Review why they have come for the test in a relaxing manner

Review their knowledge of (i) condom use, (ii) sexually transmitted diseases, (iii) HIV/AIDS. Fill in
#
the gaps in their knowledge

# Review and impress on them the consequences of risky behavior

# Assess the degree of risk for the client

# Slowly go over the nature of the test and the consequences of both a positive and negative result.

In case of a positive result review the difference between HIV and AIDS. Stress the fact that the patient
# can still live a productive life for even as long as ten or more years and the prospects for therapy and
cure are improving daily. Discuss their support system (family and friends)

In case of a negative result discuss the window period for antibody based tests and the need for
# retesting after about 4 months depending on risk assessment. Impress on them that a negative result
does not imply immunity from infection, and the need for a change in behavior.

# Obtain informed consent prior to the test.

# Schedule the next meeting a week after the test date

POST-TEST COUNSELLING (TEST NEGATIVE)

# Immediately reveal that the test was negative

# Allow time for the relief and happiness to settle.

# Reevaluate whether the person could be in the window period -- withing 3-6 months of having got the
 infection during which period negative results of tests based on detection of antibodies are not
conclusive. If there is reason for concern that this may be the case, schedule an appointment for a retest
in about 3-4 months and ask the patient to abstain from sex (or at least from unprotected sex) during
this interval

# Reassess the knowledge base and awareness of the patient

# Reinforce risk reduction information

# Explore sustainable changes in behavior

POST-TEST MEETING FOR DISCLOSING A POSITIVE RESULT

# reveal test result directly but in a gentle tone and show empathy

Allow time for ventillation of feelings. In majority of cases there is a emotional and physical
# breakdown. Allow the expression of grief through crying. Often there is denial -- it cannot happen to
me, there must be a mistake in the test. Sometimes there is a silent acceptance but tumoil within.

Once the patient has calmed down sufficiently to the point that you no longer fear that they may do
# themselves harm, reassure them of all possible help in terms of medical care, psychological support,
and referrals to specialists.

# Schedule a meeting one week later to begin therapy

POST-TEST COUNSELLING FOR A HIV POSITIVE RESULT

# Go over very carefully the difference between HIV and AIDS

Stress the benefits of a positive outlook to life in order to make the best use of the future and to stay
#
productive.

Stress the need for a good, healthy, and balanced diet. (Lots of fruits and vegetables. Avoid spicy and
#
heavy foods. Take vitamin and mineral supplements.)

# Need for regular exercise that does not cause fatigue. 15-30 minutes of brisk walking.

# Keep immune system strong. Avoid smoking, alcohol, drugs, and stress. Rest often to avoid fatigue.

# Yoga and meditation help with maintaining a positive outlook and a healthy body

Explain the need for them to minimize risky behavior to avoid transmitting the infection to another
#
person

Encourage them to continue being loving and caring parents, and to make provisions for children in
#
advance

# Review simple infection control measures in event of cuts, blood spills, hypodermic injections, etc

Review need To treat minor infections early and properly. Provide information on how to evaluate the
#
morbidity and seriousness of opportunistic infections

# Review the need for special attention to tuberculosis. Suggest regular screening for TB and for other
 opportunistic infections. Provide a referral service -- a list of sympatheic doctors with varied
specialities in case of emergency.

# Review recent developments in therapy and understanding of the disease. Offer hope for the future.

Build a support system consisting of friends and relatives. Encourage the patient to bring along one or
# more such persons to the counselling sessions. Develop a system of home based care for common
infections and even for some of the simpler opportunistic infections.

Advise confidentiality of status with associates at work and other casual associates. There is no need to
#
advertise HIV status unless patient chooses to become an activist.

Establish the need for counselling, and continue to build trust and to provide effective and regular
#
counselling.

Target Groups:
Sex Workers
MSW
MSM
Truck Drivers
Street Children
IDU
Migrant
Transgender